Universal Health Coverage: an affordable goal for all

The following commentary was authored jointly by Dr Margaret Chan and Dr Gro Harlem Brundtland, Deputy Chair of The Elders and a former WHO Director-General.

When all 193 member states of the United Nations agreed on the Sustainable Development Goals in New York last year, they set out an ambitious agenda for a safer, fairer and healthier world by 2030.

The goals include a broad array of targets across different sectors. But one target in particular stood out as a beacon of hope for a healthier world: To achieve universal health coverage (UHC). UHC is based on the principle that all individuals and communities should receive the quality health services they need without suffering financial hardship.

International and national policymakers and grassroots activists alike recognize that UHC is an idea whose time has come. In the words of Amartya Sen, the renowned Indian economist, it is an "affordable dream". And economics is on our side. We have known for many years that good health supports economic growth. The Commission on Health Employment and Economic Growth, in its report delivered in September, showed that investments in the health sector don't only result in healthier populations; they create jobs and stimulate economic growth.

UHC goes beyond safeguarding the health and well-being of individuals and communities. It also helps build fair, stable, and cohesive societies. Delivering on UHC offers employment and economic opportunities, particularly for women and youth while furthering the overarching objective of ending poverty. WHO estimates that out-of-pocket expenditures on health services push 100 million people into poverty every year. Implementing UHC would help to eliminate this impoverishment.

Some people may regard the goal of UHC as being utopian and unattainable. While it's true that no country can afford to provide every conceivable health service to every person, all countries can make progress. This has been demonstrated by the many countries in recent years that have extended coverage of vital services and improved financial protection for the population when accessing healthcare.

Japan, Moldova, Peru, Sri Lanka, Thailand and Turkey, for example, show that countries can make dramatic progress towards UHC through health system reforms that can deliver substantial health, economic and political benefits.

However, a number of countries are lagging behind their peers and are either making slow progress or leaving vulnerable groups behind. What appears to be lacking in these countries is the next generation of reforms that mobilize citizens to advocate for UHC, articulate their needs and build political momentum and commitment from governments and all stakeholders.

As WHO demonstrated in its World Health Report of 2010, health financing reforms are crucial for UHC. Most countries need to reduce reliance on private financing methods like user fees and voluntary health insurance, and instead move towards a system that is funded predominantly from public sources (i.e. various forms of taxation including compulsory social insurance contributions) that enable financial barriers to be reduced at the point of use.

Across the world, countries are realising that a free market in healthcare, with people buying and selling medical services like other commodities, will never result in UHC. In such a system, only the rich will receive adequate coverage and the poor and vulnerable will be excluded.

Increasing domestic public financing is essential. Foreign aid alone is not sufficient or sustainable. Mobilizing all segments of society to advocate for UHC is therefore vital to raise domestic financing and deliver successful reforms, often in the face of opposition from vested interests.

The evidence clearly shows that, with the right policies in place, greater public spending on health is associated with less dependence on out-of-pocket payments. This is a major challenge for some weaker economies with inadequate fiscal capacity to expand public finance significantly. For these countries in particular, strengthening domestic tax systems and cracking down on international tax evasion are essential to progress towards UHC, even as it must be recognized that the poorest countries will continue to need external aid at least for the short or medium term.

Achieving UHC and the other health-related SDG targets isn't just about spending more money. Governments need to ensure these resources are used efficiently and fairly to scale-up the supply of quality health services for everyone, with enough well-trained and motivated health workers, and to transform health systems to address the needs of people, not diseases. Health systems that achieve this don't just have better health outcomes; they also save money for individuals, households and entire countries.

We therefore recommend that countries implement health reform strategies that move swiftly towards full population coverage in an equitable way. The vital first step is to scale up primary health care services, focussing on meeting the needs of vulnerable groups such as the poor, women, girls and adolescents, as well as the disabled and older populations. To reach everyone, essential health services need to be free at the point of delivery.

Strong primary care is the lifeblood of every health system, and no country or community can achieve UHC without it. Primary care is a vital first line of defence against infectious disease outbreaks as well as tackling the slow march of non-communicable diseases, and is particularly important for the health of women and children, who are its main users.

Of course, if countries are to achieve UHC, they must be able to measure it. Monitoring both the proportion of the population with access to essential health services and the proportion of households that spend more than 25% of their income on health are the two critical indicators that have been agreed on to track progress towards UHC. The good news is that many countries already have data on both and even have more specific measures tailored to their needs, but others don't. WHO and its partners are working with countries to strengthen their health information systems.

The inclusion of UHC as one of the targets in the Sustainable Development Goals provides the platform for moving towards all other health targets through the delivery of integrated, people-centred services that span the life course, bring prevention to the fore, and protect against financial hardship. UHC is the ultimate expression of fairness and one of the most powerful social equalizers among all policy options.

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